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Research paper
Assessment of cerebral small vessel disease predicts individual stroke risk
  1. Mariëlle M F Poels1,2,
  2. Ewout W Steyerberg3,
  3. Renske G Wieberdink1,4,
  4. Albert Hofman1,
  5. Peter J Koudstaal4,
  6. M Arfan Ikram1,2,
  7. Monique M B Breteler1,5
  1. 1Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
  2. 2Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
  3. 3Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
  4. 4Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
  5. 5DZNE, German Center for Neurodegenerative Diseases, Bonn, Germany
  1. Correspondence to Mohammad Arfan Ikram, Department of Epidemiology, Erasmus MC University Medical Center, PO. Box 2040, 3000 CA Rotterdam, The Netherlands; m.a.ikram{at}


Background Despite several known risk factors it is still difficult to foresee who will develop a stroke and who will not. Vascular brain damage, visualised with MRI, reflects how the brain tolerates the effects of vascular risk factors and may therefore be relevant in predicting individual stroke risk.

Objective To examine whether the presence of small vessel disease on brain MRI could improve the prediction of stroke beyond the classic stroke risk factors from the 1991 Framingham Stroke Risk Function.

Methods 1007 community-dwelling elderly people, free of stroke at baseline were included in the study. Small vessel disease—that is, the presence of silent brain infarcts (SBI) and white matter lesions (WML), was scored on MRI scans obtained in 1995–6. 10-Year stroke risk prediction was assessed by the C statistic and by reclassification adding SBI and WML to a risk model including the classic stroke risk factors.

Results During 10-years of follow-up 99 strokes occurred. Individual stroke risk prediction significantly improved from 0.73 (95% CI 0.67 to 0.78) to 0.75 (0.69 to 0.80) in men and from 0.69 (0.64 to 0.75) to 0.77 (0.71 to 0.82) in women after inclusion of SBI and periventricular WML to the stroke risk factors. Reclassification occurred mainly in the intermediate stroke risk group (men 26%; women 61% reclassified).

Conclusions Assessment of small vessel disease with MRI beyond the classic stroke risk factors improved the prediction of subsequent stroke, especially in women with an intermediate stroke risk. These findings support the use of MRI as a possible tool for better identifying people at high risk of stroke.

  • Primary prevention
  • epidemiology
  • risk factors
  • prediction
  • neuroradiology
  • epidemiology
  • Alzheimer's disease
  • cerebrovascular disease
  • MRI
  • genetics
  • biostatistics
  • neuroepidemiology

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  • Funding The Rotterdam Study is supported by Erasmus Medical Center and Erasmus University Rotterdam, the Netherlands Organization for Scientific Research (NWO), the Netherlands Organization for Health Research and Development (ZonMW), the Research Institute for Diseases in the Elderly (RIDE), the Netherlands Genomics Initiative, the Ministry of Education, Culture and Science, the Ministry of Health, Welfare and Sports, the European Commission (DG XII) and the Municipality of Rotterdam.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the medical ethics committee of Erasmus MC University Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.